Mainframe
What does COC mean?
Continuity of Care
What does TOC mean?
Transition of Care
Give 2 examples why we deny OONR
The member needs elective surgery but the service can be safely delayed until there will be an available in network provider to perform the service.
Non Urgent (double points if both mentioned)
Can be backdate referrals?
ABSOLUTELY NOT!
What task do we open for provider concerns?
provider task
In MCS what drop down will show the PCP and PMG of the member
Primary Care Physician Information (needs to be complete)
What does PCP mean?
Really? you don't know? Of course Primary Care Physician
When are PCP change requests effective in Connecticut?
PCP change requests in Connecticut are effective on the date of the request in the current month.
Can members in New York update or change their PCP information at any time?
Yes, members in New York can update or change their PCP information at any time. However, PCP information does not appear on the NY member's ID card.
Are members in Maine allowed to request a future date for PCP changes?
No, members in Maine may not request a future date for PCP changes. The change is effective on the date of the request in the current month.
Can specialist be assigned as PCP?
NO, specialists cannot be assigned as primary care physicians/providers.
What filter shows in find care to check if the provider is a family medicine physician?
Sub-category (double the points)
If the member is CA and lets us know they want to change their Medical Group and the PCP chooses to accept the member by the fifteenth (15th) of the month, the change will take place when?
(1st) day of the next month
If there's an affected claim can we retroactively change PCP?
Yes, in certain situations, a retroactive change of primary care physician/provider is possible. The specifics depend on the plan type. location, and circumstances. READ YOUR KM!!!!!!!!!!
What's the diffrence between coordination of care and Transition of Care?
Trainer will evaluate if that's correct (too much to type)
what's the difference between tier 1 provider and tier 2 providers?
Tier 1 providers (green) have the lowest copay and meet or exceed standards for quality and cost efficiency healthcare metrics, providing high-quality care at a lower cost.
Tier 2 providers (medium copay) generally meet quality metrics but often cost more than their peers due to high rates or excess treatments, resulting in slightly higher out-of-pocket costs for members.
how do we use the ACA provider network guide?
align the state that the member lives in, check if the member is on exchange or off exchange and also check if the member is through an employer then you can identify the code you will be using in mainframe.
In mainframe after putting your domain and password you type "CA" then "PA" then from there you put "S" on the information, if "CA" is for Customer service what does "PA" stand for?
PROVIDER DATA ACCESS
What KM article are you going to check when you need to provide the time frame of the effective date of the PCP change?
PCP Changes - Current and Retroactive for All Plan Types
CA HMO Article (double points if mentioned)
Give three specialist that does not need referral?
The list is with trainer
What Filter In find care can we use to check if the provider accepts new patients?
Key Filters
Give me step by step walkthrough in mainframe after domain and password to locate the PCP ID
CA, PA, S in individual, Last name, first name, select the correct address, and BOOM you got it!
In updating PCP using the code "CM" in mainframe what do you need to put within the code "CM"?
PCP ID, Effective date, 30 and Y
The member wants to get the benefit COC and they are eligible for COC, what can the member do to get COC?
Tell the member that:
1) The provider sends the COC form with corresponding medical records
2) The member completes COC form and faxes it to UM
We use NPPES NPI registry to check the data of the member, but what does NPPES stand for?
National Plan and Provider Enumeration System (Double points)